Correct Answer: D

With improved care, women with cystic fibrosis now survive into the reproductive age and are capable of carrying a pregnancy successfully. No special precautions such as prolonged hospitalization, oxygen supplementation, bed rest, or others are necessary. Likewise, there is no need for routine cesarean section or other labor modifications, except ensuring adequate hydration and normal serum electrolytes. An amniocentesis is unnecessary. There is no constituent of amniotic fluid that is diagnostic of cystic fibrosis. Also, the fetus is at risk for cystic fibrosis only if the father is a carrier. If not, the fetus will be a carrier only. Chorionic villus biopsy can be done to determine whether the fetus has cystic fibrosis if the father carries one of the 150+ alleles for cystic fibrosis or the couple had a previously affected child. It is becoming the standard of care to screen routinely pregnant women for the cystic fibrosis gene. Currently, routine screening will identify approximately 80% of carriers of the cystic fibrosis gene.

Correct Answer: B

The main mechanism by which hemostasis is achieved following delivery is contraction of the myometrium to compress the uterine vessels that had been supplying the placenta. Lack of effective myometrial contraction (i.e., uterine atony) is the major cause of postpartum hemorrhage. If the uterus is found to be firmly contracted, then other factors, such as cervical or vaginal lacerations or a coagulopathy, must be sought.

Correct Answer: A

Constitutional delay is a normal pattern of growth, characterized by a relatively late pubertal growth spurt. It is recognized most commonly in boys. Patients typically show a moderate degree of short stature in early to middle childhood. The growth pattern is often similar to one or both parents. Final adult height is within the expected genetic potential. The children are otherwise well. Familial short stature is also a normal growth pattern in a short but otherwise normal family. One or both parents are typically 12 standard deviations below mean height for adults. The growth pattern parallels the normal growth curve at a percentile consistent with genetic potential. Deprivational dwarfism is due to psychosocial factors. It typically presents at a younger age, and weight is affected more than the height so that these children are not proportionately small. Hypothyroidism can affect growth but would cause a decrease in growth velocity when it occurred. The patient's height curve would flatten out, instead of paralleling the normal curves. Short stature from growth hormone deficiency typically presents by 3 years.

Correct Answer: B

The situation described in the question calls for clinical judgment. Restrictions should be specific and should pertain to what the patient may actually be asked to do. A company may not interdict a woman from performing a job just because she is pregnant. You should offer your best advice to a pregnant woman concerning her health and the health of the fetus. Advice should be given to patients and not to their employers. The vast majority of women can continue to do their jobs without restrictions. Telling a patient to simply avoid risk is impractical, difficult to interpret, and cannot be applied effectively. Advise and offer to write task-specific restrictions, such as, "not to climb ladders and not to lift, push, or pull with more than 20 lbs of force," or "not to work at unprotected heights such as on high ladders." The patient is well advised to discuss her needs with her employer. The physician should not communicate directly with the employer unless that is requested by the patient.

Correct Answer: B

Silicosis is considered a risk factor for the development of active TB disease for those who have contracted the infection. HIV infection, malnutrition, IV drug use, alcoholism, leukemia and other cancers, poorly controlled diabetes, severe kidney disease, immune system suppression caused by medications such as drugs to prevent rejection of a transplanted organ, and living in crowded indoor conditions, are also considered risk factors for progression to active disease. Cough variant asthma and bronchitis are not included in this list. COPD can occur as a consequence of chronic TB disease and is not considered one of the risk factors. Siderosis results from accumulation of nonfibrogenic iron oxide particles in the lung and is not considered to predispose to TB.

Correct Answer: D

The incubation period for diphtheria is 17 days. The incubation period for chicken pox is 1021 days, average 14. Infectious mononucleosis, caused by the Epstein-Barr virus, has an estimated incubation period of 3050 days. The incubation period following infection by the mumps virus is usually 1618 days but, like chicken pox, may vary from 14 to 25 days. Pertussis has a shorter incubation period, usually 710 days, with a variation of 421 days. The usual period from contamination with tetanus spores to clinical symptoms is generally 68 days. For rubella, the incubation period is from 14 to 21 days, but usually ranges from 16 to 18 days.

Correct Answer: G

The criteria for mood disorders depend on the presence or absence and duration of depressive and hypomanic or manic symptoms as well as on their severity, and also on the presence or absence of a causative general medical condition or the ingestion of substances. Major depressive disorder, recurrent, is marked by the lifetime occurrence of two or more major depressive episodes without intervening hypomanic or manic episodes. A major depressive episode is a severe depression which has lasted at least 2 weeks. Bipolar I disorder is characterized by a history of at least one full-blown manic episode, during which the patient's mood has been abnormally and persistently elevated, expansive or irritable for at least 1 week with marked impairment in occupational functioning. Bipolar II disorder, on the other hand, is marked by a history of at least one major depressive episode and at least one hypomanic episode, during which a patient's mood has been elevated, but not to the extent of causing marked impairment in social or occupational functioning. Apatient with bipolar II disorder may not, by definition, have had a full-blown manic episode.

Cyclothymia is marked by periods of hypomanic symptoms alternating with depressive symptoms that do not meet the criteria for a major depressive episode. Dysthymic disorder is marked by a persistent, low-grade depression occurring more days than not for at least 2 years. Amood disorder due to a general medical condition is a prominent and persistent disturbance in mood that is judged to be the direct physiologic effect of a general medical condition, such as hyperthyroidism. A substance-induced mood disorder is a prominent and persistent disturbance in mood that is judged to be due to the direct effects of a substance, but which continues beyond the usual period of intoxication or withdrawal from a substance.

Correct Answer: C

The mammographic appearance is most consistent with DCIS with or without an invasive component. The calcifications of DCIS are clustered, pleomorphic, irregular, and linear, and may be associated with a mass representing an invasive carcinoma. LCIS does not usually present with calcifications. Cystosarcoma phyllodes presents as a mass, often indistinguishable from a fibroadenoma. An involuting fibroadenoma often presents as a mass with large, coarse calcifications, indicating its benignity. Milk of calcium will often layer differently in the CC and mediolateral projections, suggesting fluid with calcium. The next step in management is to obtain a biopsy, preferably a core needle biopsy, for histologic confirmation and to evaluate for invasive disease. Observation is not recommended because these calcifications appear malignant. All other choices (i.e., lumpectomy or total mastectomy) are not indicated until a diagnosis by biopsy is obtained.

Correct Answer: B

This patient has idiopathic thrombocytopenic purpura (ITP), a disease characterized by a low platelet count, normal coagulation profile, increased megakaryocytes, and a normal-sized spleen. Patients with ITP will often demonstrate excessive bleeding in response to a minor injury. Circulating antiplatelet antibodies coat normal platelets, which are then sequestered by the spleen, with resultant platelet destruction. The majority of patients respond to initial therapy with systemic steroids. Splenectomy is indicated in patients who become steroid dependent with significant side effects or in patients requiring increasing doses of steroids to maintain a satisfactory platelet count. The entire spleen must be excised, including any accessory spleens found at surgery. Residual splenic parenchyma would result in persistent platelet sequestration. Splenectomy is not indicated in the initial management of ITP. Platelet transfusion is rarely required. Spontaneous bleeding is unusual unless the platelet counts drop below 20,000/L. When this occurs, if the patient is not responsive to steroids, platelet transfusion and urgent splenectomy is indicated. Antineoplastic chemotherapy is not used in the management of ITP. Expectant management is associated with significant risk, as the most life- threatening complication of ITP is spontaneous intracerebral hemorrhage. Bone marrow transplant is not indicated. ITP is a disease of peripheral platelet destruction, with normal or increased platelet production.

Correct Answer: B

Ruptured cerebral aneurysms often occur in the setting of hypertension. The severe headache, nausea and vomiting, photophobia, and nuchal rigidity are the result of meningeal irritation from subarachnoid blood. Subarachnoid hemorrhage is visualized on CT scan, with definitive diagnosis of the aneurysm and its location by cerebral angiography. Early surgical clipping is the current neurosurgical approach because of the significant risk of rebleeding in the first 24 hours after initial presentation. Hydrocephalus may occur as a late complication of subarachnoid hemorrhage and require serial lumbar puncture to drain CSF and control ICP. A hemorrhagic stroke can occur in association with malignant hypertension and may have concurrent subarachnoid hemorrhage. Focal neurologic signs are usually present. Meningitis will produce similar signs of meningeal irritation, but usually with other systemic signs of infection and a clinical prodromesuggesting an infectious etiology. Lumbar puncture is diagnostic, and if a bacterial source is suspected, systemic antibiotics are initiated pending culture of CSF. Ischemic cerebrovascular accidents and transient ischemic attacks are not associated with subarachnoid hemorrhage and, hence, do not present with signs of meningeal irritation. Focal neurologic signs are usually present. Evaluation of a possible cause includes Doppler examination of the carotid arteries. Management includes anticoagulation and antiplatelet therapy. EEG measures brain electrical activity and is indicated in the diagnostic evaluation of seizures.